GM Case

This is an online e-log platform to discuss case scenario of a patient with their guardians permission. 

 I have been given this case to solve in an attempt to understand the topic of patient clinical data analysis to develop my competency in reading and comprehending clinical data including, history, clinical findings,investigations,and come up with a diagnosis and treatment plan. 

Case:
A 36 year old male cement factory worker by occupation came to the opd with chief complains of abdominal distension and abdominal pain which is in right loin radiating to groin associated with decreased urine output since 5 days

HISTORY OF PRESENT ILLNESS:
Patient was apparently asymptomatic 1 year back, then he developed abdominal pain and diagnosed to have renal calculi, for which he took treatment and symptoms got subsided. 
He developed pain abdomen and abdominal distension 5 days back associated with decreased urine output 
No h/o of chest pain, palpitations, shortness of breath

HISTORY OF PAST ILLNESS:
Not a k/c/o of DM, HTN, Epilepsy, CAD, TB
No h/o surgeries

TREATMENT HISTORY:
Not significant

PERSONAL HISTORY:
Appetite- normal
Mixed diet
Bowel movements- regular
Micturition - decreased
No drug allergy
Alcohol consumption since 15 years

FAMILY HISTORY:
Not significant

GENERAL EXAMINATION:
Patient is conscious, coherent, cooperative
Icterus is seen
Absence of pallor, Cyanosis, clubbing, lymphadenopathy, edema

VITALS:
Temperature: Afebrile
Pulse rate: 76 bpm
Respiratory rate:28 cpm
BP: 120/70 mm of hg
Spo2 : 98% at room air

SYSTEMIC EXAMINATION:

CARDIOVASCULAR SYSTEM:
Thrills absent
S1, S2 heard
No murmurs

RESPIRATORY SYSTEM:
Normal vesicular breath sounds
Position of trachea is central
No dyspnoea 
No wheeze

ABDOMEN:
shape of abdomen- distended
No tenderness
No palpable mass
Normal hernial orifices
No free fluid
No bruits
Liver and spleen are not palpable
Bowel sounds heard

CENTRAL NERVOUS SYSTEM:
Patient is conscious
Speech-normal
No signs of meningeal irritation
Motor and sensory system is intact

Investigations:


























PROVISIONAL DIAGNOSIS:

POST RENAL AKI SECONDARY TO URETERIC  CALCULI WITH URINARY STASIS WITH ACUTE PANCREATITIS

TAB RANTAC 150 mg  PO/BD

22/06/22

INJ MEROPENEM 500 mg IV/ OD

IVF ND @100 ml/ hr

INJ LASIX 40 mg /IV/BD

INJ ZOFER 4 mg IV/BD

INJ TRAMADOL 1 amp 100ml NS/ IV/TID

TAB UDILIV 300 mg PO/TID

TAB RANTAC 150 mg  PO/BD

23/06/22

INJ MEROPENEM 500 mg IV/ OD

IVF ND @100 ml/ hr

INJ LASIX 40 mg /IV/BD

INJ ZOFER 4 mg IV/BD

INJ TRAMADOL 1 amp 100ml NS/ IV/TID

TAB UDILIV 300 mg PO/TID

TAB RANTAC 150 mg  PO/BD.

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